Healthcare Provider Details

I. General information

NPI: 1992530356
Provider Name (Legal Business Name): LISA L WATSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 VT ROUTE 11 W
CHESTER VT
05143-9202
US

IV. Provider business mailing address

420 QUARRY RD
PERKINSVILLE VT
05151-9608
US

V. Phone/Fax

Practice location:
  • Phone: 802-875-2878
  • Fax: 802-875-6696
Mailing address:
  • Phone: 802-376-4274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number015.0001537
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: